Examining the Role of Vocational Rehabilitation on Access to Care and Public Health Outcomes for People Living with HIV/AIDS

The purpose of this study is to examine the role of vocational rehabilitation services in contributing to the goals of the National HIV/AIDS strategy. Three key research questions are addressed: (a) What is the relationship among factors associated with the use of vocational rehabilitation services for people living with HIV/AIDS? (b) Are the factors associated with use of vocational rehabilitation also associated with access to health care, supplemental employment services and reduced risk of HIV transmission? And (c) What unique role does use of vocational rehabilitation services play in access to health care and HIV prevention? Survey research methods were used to collect data from a broad sample of volunteer respondents who represented diverse racial (37% Black, 37% White, 18% Latino, 7% other), gender (65% male, 34% female, 1% transgender) and sexual orientation (48% heterosexual, 44% gay, 8% bisexual) backgrounds. The fit of the final structural equation model was good (root mean square error of approximation = .055, Comparative Fit Index=.953, Tucker Lewis Index=.945). Standardized effects with bootstrap confidence intervals are reported. Overall, the findings support the hypothesis that vocational rehabilitation services can play an important role in health and prevention strategies outlined in the National HIV/AIDS strategy.

Digital Systems for Open Access to Formal and Informal Learning

Today, Digital Systems and Services for Technology Supported Learning and Education are recognized as the key drivers to transform the way that individuals, groups and organizations “learn” and the way to “assess learning” in 21st Century. These transformations influence: Objectives - moving from acquiring new “knowledge” to developing new and relevant “competences”; Methods – moving from “classroom” based teaching to “context-aware” personalized learning; and Assessment – moving from “life-long” degrees and certifications to “on-demand” and “in-context” accreditation of qualifications. Within this context, promoting Open Access to Formal and Informal Learning, is currently a key issue in the public discourse and the global dialogue on Education, including Massive Open Online Courses (MOOCs) and Flipped School Classrooms. This volume on Digital Systems for Open Access to Formal and Informal Learning contributes to the international dialogue between researchers, technologists, practitioners and policy makers in Technology Supported Education and Learning. It addresses emerging issues related with both theory and practice, as well as, methods and technologies that can support Open Access to Formal and Informal Learning. In the twenty chapters contributed by international experts who are actively shaping the future of Educational Technology around the world, topics such as: - The evolution of University Open Courses in Transforming Learning - Supporting Open Access to Teaching and Learning of People with Disabilities - Assessing Student Learning in Online Courses - Digital Game-based Learning for School Education - Open Access to Virtual and Remote Labs for STEM Education - Teachers’ and Schools’ ICT Competence Profiling - Web-Based Education and Innovative Leadership in a K-12 International School Setting are presented. An in-depth blueprint of the promise, potential, and imminent future of the field, Digital Systems for Open Access to Formal and Informal Learning is necessary reading for researchers and practitioners, as well as, undergraduate and postgraduate students, in educational technology.

Does Immediate Access to Birth Control Help Prevent Pregnancy? A Comparison of Onsite Provision Versus Off Campus Referral for Contraception at Two School-Based Clinics

PURPOSE: The purpose of this study was to assess the impact of different policies on access to hormonal contraception and pregnancy rates at two high school-based clinics. METHODS: Two clinics in high schools (Schools A and B), located in a large urban district in the southwest US, provide primary medical care to enrolled students with parental consent; the majority of whom have no health insurance coverage. The hormonal contraceptive dispensing policy of at School clinic A involves providing barrier, hormonal and emergency contraceptive services on site. School clinic B uses a referral policy that directs students to obtain contraception at an off-campus affiliated family planning clinic. Baseline data (age, race and history of prior pregnancy) on female students seeking hormonal contraception at the two clinics between 9/2008-12/2009 were extracted from an electronic administrative database (AHLERS Integrated System). Data on birth control use and pregnancy tests for each student was then tracked electronically through 3/31/2010. The outcomes measures were accessing hormonal contraception and positive pregnancy tests at any point during or after birth control use were started through 12/2009. The appointment keeping rate for contraceptive services and the overall pregnancy rates were compared between the two schools. In addition the pregnancy rates were compared between the two schools for students with and without a prior history of pregnancy. RESULTS: School clinic A: 79 students sought hormonal contraception; mean age 17.5 years; 68% were > 18 years; 77% were Hispanic; and 20% reported prior pregnancy. The mean duration of the observation period was 13 months (4-19 months). All 79 students received hormonal contraception (65% pill and 35% long acting progestin injection) onsite. During the observation period, the overall pregnancy rate was 6% (5/79); 4.7% (3/63) among students with no prior pregnancy. School clinic B: 40 students sought hormonal contraception; mean age 17.5 years; 52% > 18 years; 88 % were Hispanic; and 7.5% reported prior pregnancy. All 40 students were referred to the affiliated clinic. The mean duration of the observation period was 11.9 months (4-19 months). 50% (20) kept their appointment. Pills were dispensed to 85% (17/20) and 15% (3/20) received long acting progestin injection. The overall pregnancy rate was 20% (8/40); 21.6% (8/37) among students with no prior pregnancy. A significantly higher frequency of students seeking hormonal contraception kept their initial appointment for birth control at the school dispensing onsite contraception compared to the school with a referral policy for contraception (p<0.05). The pregnancy rate was significantly higher for the school with a referral policy for contraception compared to the school with onsite contraceptive services (p< 0.05). The pregnancy rate was also significantly higher for students without a prior history of pregnancy in the school with a referral policy for contraception (21.6%) versus the school with onsite contraceptive services (4.7%) (p< 0.05). CONCLUSION: This preliminary study showed that School clinic B with a referral policy had a lower appointment keeping rate for contraceptive services and a higher pregnancy rate than School clinic A with on-site contraceptive services. An on-site dispensing policy for hormonal contraceptives at high school-based health clinics may be a convenient and effective approach to prevent unintended first and repeat pregnancies among adolescents who seek hormonal contraception. This study has strong implications for reproductive health policy, especially as directed toward high-risk teenage populations.

Racial Disparities in Access to and Outcomes of Kidney Transplantation in Children, Adolescents, and Young Adults: Results From the ESPN/ERA-EDTA (European Society of Pediatric Nephrology/European Renal Association-European Dialysis and Transplant Association) Registry.

BACKGROUND Racial disparities in kidney transplantation in children have been found in the United States, but have not been studied before in Europe. STUDY DESIGN Cohort study. SETTING & PARTICIPANTS Data were derived from the ESPN/ERA-EDTA Registry, an international pediatric renal registry collecting data from 36 European countries. This analysis included 1,134 young patients (aged ≤19 years) from 8 medium- to high-income countries who initiated renal replacement therapy (RRT) in 2006 to 2012. FACTOR Racial background. OUTCOMES & MEASUREMENTS Differences between racial groups in access to kidney transplantation, transplant survival, and overall survival on RRT were examined using Cox regression analysis while adjusting for age at RRT initiation, sex, and country of residence. RESULTS 868 (76.5%) patients were white; 59 (5.2%), black; 116 (10.2%), Asian; and 91 (8.0%), from other racial groups. After a median follow-up of 2.8 (range, 0.1-3.0) years, we found that black (HR, 0.49; 95% CI, 0.34-0.72) and Asian (HR, 0.54; 95% CI, 0.41-0.71) patients were less likely to receive a kidney transplant than white patients. These disparities persisted after adjustment for primary renal disease. Transplant survival rates were similar across racial groups. Asian patients had higher overall mortality risk on RRT compared with white patients (HR, 2.50; 95% CI, 1.14-5.49). Adjustment for primary kidney disease reduced the effect of Asian background, suggesting that part of the association may be explained by differences in the underlying kidney disease between racial groups. LIMITATIONS No data for socioeconomic status, blood group, and HLA profile. CONCLUSIONS We believe this is the first study examining racial differences in access to and outcomes of kidney transplantation in a large European population. We found important differences with less favorable outcomes for black and Asian patients. Further research is required to address the barriers to optimal treatment among racial minority groups.

Government initiatives to expand access to employer-based health insurance

Employer-based health insurance is declining at records rates, which leaves an increasing number of people without access to affordable health insurance. As a result, municipalities are experiencing financial difficulties to provide health care services for their growing uninsured population. In attempt to combat this issue, three health polices have emerged within the last ten years, called Living Wage with a health insurance provision, Pay or Play, and Health Care Preference. These policies are gaining popularity as civic leaders recognize their ability to promote a public health goal by leveraging the power of city and county contracts to include a health insurance component in the competitive bidding practice for government contracts. ^ This is the first paper to conduct a retrospective analysis on whether these three health policies have been able to increase access to employer-based health insurance and/or support the local health care safety net based on the experiences of six municipalities over a 5-year period from 2001-2006. Although there was variation between the effectiveness of the policies, all three demonstrated success in that a number of contractors extended existing health insurance to employees not previously covered and the increased cost of contracting for the local government was, on average, less than 1 percent of the total operating budget. ^

Understanding causes of hospitalization and access to care among newly diagnosed HIV patients in Houston, TX

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings most often with advanced HIV related conditions.(1) There has been little research done on the causes of hospitalization when the patients are first diagnosed with HIV. The aim of this study was to determine if the patients are hospitalized due to an HIV related cause or due to some other co-morbidity. Reduced access to care could be one possible reason why patients are diagnosed late in the course of the disease. This study compared the access to care of patients diagnosed with HIV in hospital and outpatient setting. The data used for the study was a part of the ongoing study “Attitudes and Beliefs and Steps of HIV Care”. The participants in the study were newly diagnosed with HIV and recruited from both inpatient and outpatient settings. The primary and the secondary diagnoses from hospital discharge reports were extracted and a primary reason for hospitalization was ascertained. These were classified as HIV-related, other infectious causes, non–infectious causes, other systemic causes, and miscellaneous causes. Access to care was determined by a score based on responses to a set of questions derived from the HIV Cost and Services Utilization Study (HCSUS) on a 6 point scale. The mean score of the hospitalized patients and mean score of the patients diagnosed in an outpatient setting was compared. We used multiple linear regressions to compare mean differences in the two groups after adjusting for age, sex, race, household income educational level and health insurance at the time of diagnosis. There were 185 participants in the study, including 78 who were diagnosed in hospital settings and 107 who were diagnosed in outpatient settings. We found that HIV-related conditions were the leading cause of hospitalization, accounting for 60% of admissions, followed by non-infectious causes (20%) and then other infectious causes (17%). The inpatient diagnosed group did not have greater perceived access-to-care as compared to the outpatient group. Regression analysis demonstrated a statistically significant improvement in access-to-care with advancing education level (p=0.04) and with better health insurance (p=0.004). HIV-related causes account for many hospitalizations when patients are first diagnosed with HIV. Many of these HIV-related hospitalizations could have been prevented if patients were diagnosed early and linked to medical care. Programs to increase HIV awareness need to be an integral part of activities aimed at control of spread of HIV in the community. Routine testing for HIV infection to promote early HIV diagnosis can prevent significant morbidity and mortality.^

Homeless access to dental health care: Creation of a dental service model

This project involved developing a model for planning a dental emergency treatment center that could function as an embedded component of a shelter for the homeless population. The dental services provided by such a clinic should include treatment for tooth pain, dental caries or cavities, chipped or broken teeth, broken partials, abscessed teeth, emergency cleanings, periodontal disease or gum disease and fillings. These are the dental services that are most often sought by homeless people in hospital emergency rooms.^ The underlying assumption for this project was that the oral health needs of the homeless community can most effectively be addressed by implementing small dental clinics in existing facilities that provide shelter and other services for this population. The model described in this project identifies oral health care services that would be provided by the clinic, facility (physical plant) requirements and associated infrastructure to operate an embedded dental clinic, methods for obtaining funding, strategies of recruiting dental professionals to staff the facility, and methods to assess the outcomes of the embedded clinic strategy. As an example, this project describes a strategy for developing such an embedded clinic at San Antonio Metropolitan Ministries SAMM shelter based on recommendations from community health care leaders, managers of homeless shelters, members of the homeless community and dental professionals^

FACTORS INFLUENCING ACCESS TO HEALTH CARE AMONG MEXICAN AMERICAN ELDERLY IN TEXAS

Differential access to health care services has been observed among various groups in the United States. Minorities and low-income groups have been especially notable in their decreased access to regular providers of care. This is believed by many to account for some of the higher rates of morbidity and mortality and shorter life expectancies of these groups.^ This research delineated the factors associated with health care access for a particular subset of a minority group, the Mexican American elderly in Texas. Hospital admission and evidence of a regular source of medical care and dental care were chosen as the indicators of access to health care.^ This study analyzed survey interview data from the Texas Study on Aging, 1976. The 597 Mexican American elderly included in this study were representative of the non-institutionalized Mexican American elderly in Texas aged 55 or older.^ The results indicate that hospital admission is not a question of discretion and that common barriers to access, such as income, health insurance, and distance to the nearest facility, are not important in determining hospital admission. Mexican American elderly who need to be hospitalized, as indicated by self-perception of health and disability days, will be hospitalized.^ The results also indicate that having a regular source of medical care is influenced by many factors, some mutable and some immutable. The well-established and immutable factors of age, sex, and need were confirmed. However, the mutable factors such as area of residence and income were also found to have a significant influence. Mexican American elderly living in urban areas had significantly less access to a regular source of medical care as did those who were near the poverty level (as opposed to those who were well below the poverty level). In general, persons claiming a regular source of medical care were more likely to be women, persons who had many health needs, were near the poverty level, lived in urban areas, and had extensive social support systems.^ Persons claiming a regular source of dental care tended to be more advantaged. They had more education, a more extensive informal social support network, higher income, and were generally younger and in better health. They were also more likely to have private health insurance. . . . (Author's abstract exceeds stipulated maximum length. Discontinued here with permission of author.) UMI ^

A New Multidisciplinary Home Care Telemedicine System to Monitor Stable Chronic Human Immunodeficiency Virus-Infected Patients: A Randomized Study

BACKGROUND: Antiretroviral therapy has changed the natural history of human immunodeficiency virus (HIV) infection in developed countries, where it has become a chronic disease. This clinical scenario requires a new approach to simplify follow-up appointments and facilitate access to healthcare professionals. METHODOLOGY: We developed a new internet-based home care model covering the entire management of chronic HIV-infected patients. This was called Virtual Hospital. We report the results of a prospective randomised study performed over two years, comparing standard care received by HIV-infected patients with Virtual Hospital care. HIV-infected patients with access to a computer and broadband were randomised to be monitored either through Virtual Hospital (Arm I) or through standard care at the day hospital (Arm II). After one year of follow up, patients switched their care to the other arm. Virtual Hospital offered four main services: Virtual Consultations, Telepharmacy, Virtual Library and Virtual Community. A technical and clinical evaluation of Virtual Hospital was carried out. FINDINGS: Of the 83 randomised patients, 42 were monitored during the first year through Virtual Hospital (Arm I) and 41 through standard care (Arm II). Baseline characteristics of patients were similar in the two arms. The level of technical satisfaction with the virtual system was high: 85% of patients considered that Virtual Hospital improved their access to clinical data and they felt comfortable with the videoconference system. Neither clinical parameters [level of CD4+ T lymphocytes, proportion of patients with an undetectable level of viral load (p = 0.21) and compliance levels >90% (p = 0.58)] nor the evaluation of quality of life or psychological questionnaires changed significantly between the two types of care. CONCLUSIONS: Virtual Hospital is a feasible and safe tool for the multidisciplinary home care of chronic HIV patients. Telemedicine should be considered as an appropriate support service for the management of chronic HIV infection. TRIAL REGISTRATION: Clinical-Trials.gov: NCT01117675.

WormBase: network access to the genome and biology of Caenorhabditis elegans

WormBase (http://www.wormbase.org) is a web-based resource for the Caenorhabditis elegans genome and its biology. It builds upon the existing ACeDB database of the C.elegans genome by providing data curation services, a significantly expanded range of subject areas and a user-friendly front end.

A metasynthesis of qualitative studies regarding opinions and perceptions about barriers and determinants of health services’ accessibility in economic migrants

Background: Access to health services is an important health determinant. New research in health equity is required, especially amongst economic migrants from developing countries. Studies conducted on the use of health services by migrant populations highlight existing gaps in understanding which factors affect access to these services from a qualitative perspective. We aim to describe the views of the migrants regarding barriers and determinants of access to health services in the international literature (1997–2011). Methods: A systematic review was conducted for Qualitative research papers (English/Spanish) published in 13 electronic databases. A selection of articles that accomplished the inclusion criteria and a quality evaluation of the studies were carried out. The findings of the selected studies were synthesised by means of metasynthesis using different analysis categories according to Andersen’s conceptual framework of access and use of health services and by incorporating other emergent categories. Results: We located 3,025 titles, 36 studies achieved the inclusion criteria. After quality evaluation, 28 articles were definitively synthesised. 12 studies (46.2%) were carried out in the U.S and 11 studies (42.3%) dealt with primary care services. The participating population varied depending mainly on type of host country. Barriers were described, such as the lack of communication between health services providers and migrants, due to idiomatic difficulties and cultural differences. Other barriers were linked to the economic system, the health service characteristics and the legislation in each country. This situation has consequences for the lack of health control by migrants and their social vulnerability. Conclusions: Economic migrants faced individual and structural barriers to the health services in host countries, especially those with undocumented situation and those experimented idiomatic difficulties. Strategies to improve the structures of health systems and social policies are needed.

Is health a right for all? An umbrella review of the barriers to health care access faced by migrants

Objective. To synthesise the scientific evidence concerning barriers to health care access faced by migrants. We sought to critically analyse this evidence with a view to guiding policies. Design. A systematic review methodology was used to identify systematic and scoping reviews which quantitatively or qualitatively analysed data from primary studies. The main variables analysed were structural and contextual barriers (health system organisation) as well as individual (patients and providers). The quality of evidence from the systematic reviews was critically appraised. From 2674 reviews, 79 were retained for further scrutiny, and finally 9 met the inclusion criteria. Results. The structural barriers identified were the lack of health insurance and the high cost of drugs (non-universal health system) and organisational aspects of health system (social insurance system and national health system). The individual barriers were linguistic and cultural. None of the reviews provided a quality appraisal of the studies. Conclusions. Barriers to health care for migrants range from entitlement in non-universal health systems to accessibility in universal ones, and determinants of access to the respective health services should be analysed within the corresponding national context. Generate social and institutional changes that eliminate barriers to access to health services is essential to ensure health for all.

Barriers and facilitators to effective coverage of Intimate Partner Violence services for immigrant women in Spain

Objective: To explore service providers’ perceptions in order to identify barriers and facilitators to effective coverage of Intimate Partner Violence (IPV) services for immigrant women in Spain, according to the different categories proposed in Tanahashi's model of effective coverage. Methods: A qualitative study based on 29 in-depth personal interviews and four group interviews with a total of 43 professionals working in public services (social and health-care services, women's refuges, the police force, the judiciary) and NGOs in Barcelona, Madrid, Valencia and Alicante (Spain) in 2011. Findings: Current IPV services in Spain partially fail in their coverage of abused immigrant women due to barriers of (i) availability, such as the inexistence of culturally appropriate services; (ii) accessibility, as having a residence permit is a prerequisite for women's access to different services and rights; (iii) acceptability, such as women's lack of confidence in the effectiveness of services; and (iv) effectiveness, for example, lack of specific training among professionals on the issues of IPV and immigration. However, interviewees also identified facilitators, such as the enabling environment promoted by the Spanish Law on Gender-Based Violence (1/2004), and the impetus it has provided for the development of other specific legislative tools to address IPV in immigrant populations in Spain (availability, accessibility and effectiveness). Conclusion: Whilst not dismissing cultural barriers, aspects related to service structure are identified by providers as the main barriers and facilitators to immigrant women use of IPV services. Despite noteworthy achievements, improvements are still required in terms of mainstreaming assistance tailored to immigrant women's needs in IPV policies and services.

Barriers to health care/children's health [microform] : hearing before the Committee on Labor and Human Resources, United States Senate, Ninety-ninth Congress, second session, on review of access to health care for the poor and uninsured and improved health for America's children, July 16, 1986.

CIS Microfiche Accession Numbers: CIS 87 S541-16