"Community" as the ideal for health care reform.
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Community Health Planning↗
Biomedical subjects
L A Aday
Publications and source records attributed to L A Aday.
Managed care and community-oriented care: conflict or complement?
Motivated by the need for fundamental change, reform of the health care delivery system is continuing despite the recent failure of national initiatives. One aspect of this reform is the restructuring of managed care systems to include low-income, at-risk populations in their health delivery program: It is a move that threatens current "safety-net" providers, which already serve these populations with programs that combine public health and traditional primary care. This paper explores this potential conflict by providing a brief history and comparison of the main features of the community-oriented primary care (COPC) and health maintenance organization (HMO) models. The authors provide a frame-work that contrasts the structure, process, and outcome characteristics of these two models, delineating key similarities and differences. The frame-work is used in profiling a service delivery system model that integrates the two systems and in discussing issues related to operationalizing the proposed integration.
Community Health Planning↗
Patient satisfaction in government health facilities in the state of Qatar.
There is an increasing interest in assessing patients' satisfaction with medical care in the United States and other countries. Patient satisfaction studies have, however, received comparatively little attention in public or government-sponsored settings, and in developing countries in particular. The research reported upon here is based on a mail, self-administered survey of patients receiving care in two major government outpatient health care facilities-Hamad General Hospital and the Khalifa Town Health Center-in the State of Qatar, for the purpose of providing data to improve service delivery and the quality of primary care provided in that country. Analysis was performed on data from 444 patients on seven dimensions of patient satisfaction with medical care: general satisfaction, availability of services, convenience of services, facilities (physical environment), humaneness of doctors, quality of care, and continuity of care. The study pointed to a number of deficiencies in the availability and delivery of services in government health facilities in the State of Qatar. It also surfaced methodological issues that should be addressed in comparable studies of culturally diverse populations.
Adolescent↗
Barriers to cancer treatment: a review of published research.
PURPOSE/OBJECTIVES: To review published research on barriers to cancer treatment to provide a foundation for subsequent research and program and policy development directed at diminishing these barriers. DATA SOURCES: Relevant literature from medical and behavioral science data bases published between 1964 and 1994. Researchers reviewed 752 abstracts; they identified 160 articles that related directly to research on barriers to cancer treatment. Of these 160 articles, researchers chose 61 for a subsequent review using criteria to evaluate the strength of the study design and sampling procedures. DATA SYNTHESIS: The major barriers consistently documented to influence whether or not patients with cancer sought or continued treatment included communication problems between patients and providers, lack of information on side effects, cost of treatment, difficulties in obtaining and maintaining insurance coverage, and absence of social support networks. Access barriers generally were greater for older women, members of minority groups, and patients of lower socioeconomic status. The vast majority of the studies were conceptual or descriptive in nature and were based on nonprobability clinic-based samples. CONCLUSIONS: The limitations of existing research point to the need for studies on barriers to cancer treatment based on analytic population-based study designs that examine the relative importance of factors derived from multivariate explanatory models. This information may be used to develop programs and policies to ameliorate treatment barriers for patients with cancer. IMPLICATIONS FOR NURSING PRACTICE: The research priorities set forth by the Oncology Nursing Society also indicate a need for this type of research because quality of life, cost containment, and outcomes assessment all are directly or indirectly affected by the timely diagnosis of cancer. Treatment barriers have the potential to significantly affect an individual's ability to seek care and ultimately to increase the cost of care associated with adverse outcomes that may result from delays in seeking treatment.
Female↗
Estimating the risks and prevalence of hypertension in a suburban area of Beijing.
Community-oriented primary care (COPC) provides a framework for identifying and addressing a defined community's health and health care needs. The research reported upon here is based on a community health survey in a new suburban neighborhood (Tayuan region) in the Haidian district of Beijing, conducted by the Beijing Medical University Department of Preventive Medicine and Health Care, to serve as a basis for planning health care services for the residents in that community. The analyses focus on the prevalence and predictors of hypertension among older adult residents (those 45 years of age and older). Based on logistic regression analyses, the odds ratios (in parentheses) confirm that individuals with a family history of cardiovascular disease were more likely to have been diagnosed as hypertensive (1.57). Hypertensives were also more likely to have uncontrolled systolic (3.85) or diastolic (4.75) blood pressure and associated behavioral and biologic risks, such as obesity (1.87) and renal damage (2.60). These risks were even greater among current or former smokers. These analyses will inform the design of community-oriented primary care interventions in that particular community in the People's Republic of China. They also signal important implications and highlight practical methods for assessing and targeting interventions in U.S. communities facing comparable, but unexamined, risks.
Aged↗
Health status of vulnerable populations.
The notion of risk underlying the concept of vulnerability implies that everyone is potentially vulnerable (or at risk), that is, there is always a chance of developing health problems. The risk is, however, greater for those with the least social status, social capital, and human capital resources to either prevent or ameliorate the origins and consequences of poor physical, psychological, or social health. The completeness and accuracy of information on the health status of the vulnerable populations examined here varies substantially across groups. Methodological work is needed to derive standardized definitions of terms, specify the content and timing for collecting information for minimum basic data sets, and develop uniform standards for evaluating and reporting data quality on the health status of vulnerable populations. The variety of indicators of vulnerable populations examined indicates that during the decade of the 1980s the incidence of serious physical, psychological, and/or social needs increased (at worst) and was unameliorated (at best) for millions of Americans. AIDS emerged as a new and deadly threat from a handful of cases classified as Gay-Related Immune Deficiency in the early part of the 1980s to what now may be over a million Americans who are HIV-positive. The number of homeless has increased an average of 20% a year to estimates now ranging up to one million men, women, or children homeless on any given night to twice that number who may be homeless sometime during the year. Over seven million people immigrated to the United States during the period from 1981 to 1990--an increasing proportion of whom are refugees carrying with them the physical, psychological, and social wounds of war. The number of children abused by family members or other intimates has burgeoned to an estimated 1.6 to 1.7 million per year, and with the greater use of firearms, intentional acts of violence towards oneself or others are becoming increasingly deadly in their consequences. Though fewer Americans smoke, drink, and use illicit drugs in general than was the case earlier in the decade of the 1980s, the use of cocaine (and particularly crack) among hard-core addicts has resulted in increases in the number of drug-related deaths.(ABSTRACT TRUNCATED AT 400 WORDS)
Acquired Immunodeficiency Syndrome↗
Family physicians' support for school-based HIV prevention education programs.
OBJECTIVE: To identify the extent to which family physicians support school-based education programs regarding the human immunodeficiency virus (HIV). Sexually active adolescents are at risk for infection with HIV. Education programs on HIV that target this vulnerable group effectively prevent infection, yet family physicians are often not directly involved in the design and implementation of such programs. DESIGN: A systematic random sample of 2660 members of the American Academy of Family Physicians was surveyed using a mailed questionnaire to assess clinical experiences with HIV disease, willingness to provide HIV treatment, and support for school-based HIV education programs. The response rate was 63.7%. Poststratification weights were applied to adjust for the slight under-representation of non-board-certified physicians in the study sample. RESULTS: Support for school-based HIV counseling programs was overwhelmingly positive. The mean level of support was 1.28 (with 1 indicating strong approval and 4 strong disapproval). Physicians' attitudes toward programs that include condom availability were marginally less favorable (1.92). Residency trained (P = .009) and female physicians (P = .010) expressed the greatest support for school-based programs. Physicians with fewer professional concerns about providing direct HIV patient care (P = .030) and who believed that communication with their patients about sexuality was an acceptable component of clinical care (P < .001) were most likely to support school-based programs. CONCLUSIONS: Family physicians can play an important role in designing and implementing HIV education programs. The results of these analyses suggest family physicians may be relied on to endorse school-based HIV prevention programs, including programs that make condoms available to adolescents. School and public health authorities should enlist family physicians' assistance when planning and implementing these or related community-based HIV education activities.
Acquired Immunodeficiency Syndrome↗
Health insurance and utilization of medical care for children with special health care needs.
Based on analyses of the 1988 National Center for Health Statistics, National Health Interview Survey, Child Health Supplement, this study examines the insurance coverage and utilization of physicians, hospitals, and prescribed medicine among the 9.6 million U.S. children with special health care needs, defined as children who had one or more selected chronic conditions that caused them to experience pain, discomfort, or being upset often or all of the time in the last year, or who were limited in their major childhood activities (playing or going to school) as a result of these or other impairments or health problems. The findings confirmed that substantial variation in access to routine medical care exists among these children. Though health status is an important predictor of which children use services in general, poor, minority children who lived with their mother or someone other than their parents, or those without insurance or an identifiable regular medical provider were most likely to experience financial barriers to access or were less apt to seek care than other children with comparable needs. Access to routine medical care remains particularly problematic for these subsets of children with special health care needs.
Adolescent↗
Health insurance and utilization of medical care for chronically ill children with special needs. Health of our nation's children, United States, 1988.
In summary, a substantial proportion of Hispanic and low-income chronically ill children with special needs have neither private insurance nor Medicaid coverage. Those who averaged the fewest doctor visits during the past year for their condition (such as black or low-income children) also tended to be more likely to be hospitalized. Children who did not live with a biological mother or biological mother and father were least likely to have been to a physician or to be taking prescribed medications for their condition. These analyses pinpoint chronically ill children with special needs who are likely to have the least access to routine medical care. Further research is warranted to estimate the probable impact of the differential nonresponse and underreporting by minority and low-income respondents on these estimates.
Adolescent↗
A profile of black and Hispanic subgroups' access to dental care: findings from the National Health Interview Survey.
This study examined which black and Hispanic minority subgroups were least likely to obtain dental care and why, based on logistic regression analyses of the 1986 National Health Interview Survey. Blacks and Hispanics were less apt to have private dental insurance coverage, to be knowledgeable about the purpose of fluoride, to have been to a dentist in the past year, and, when they did go, were more apt to have gone in response to symptoms rather than for preventive reasons, compared to whites. Logistic regression analyses for adults 18 years of age and older and for children and adolescents 2 to 17 years of age showed that the following individuals had the lowest probability of having been to a dentist in the past year: males, members of larger families, adults who were unemployed or in blue-collar jobs, those who lived in the South or nonmetropolitan areas, people who perceived their health to be fair or poor, and those with no private dental insurance. Mexican-Americans were least likely to have been to a dentist regardless of their income or education. In general, the findings confirmed the importance of dental insurance, as well as suggesting a need for more school-based dental programs and public health clinic-based dental health education and outreach efforts for targeting minority children and adults.
Adolescent↗
Family physician attitudes about HIV screening.
This study examined why and for whom family physicians are likely to require HIV screening according to general policies or procedures, based on a national survey of 2,660 family practice physicians. Of those contacted, 1,678 responded, yielding a response rate of 63.7%. The study also examined whether attitudes toward screening differed for physicians in different types of practices, of varying educational backgrounds, and with differing opinions regarding treating persons with AIDS (PWAs). The results showed that required screening was most strongly endorsed for pregnant women who had other risk factors and for i.v. drug users. Those physicians who most favored mandatory screening were also most likely to favor the mandatory reporting of AIDS cases to public health officials. They also had the least formal medical training (were not residency trained or board certified) and expressed the greatest apprehension regarding their own and their staff's preparedness and willingness to treat PWAs. A major implication of the findings is that family physicians and others who do mandatory testing should be provided opportunities, through residency training, board-certification preparation, or continuing medical education, to learn how to care for those patients they test who turn out to be seropositive.
AIDS Serodiagnosis↗
A framework for community assessment: designing and conducting a survey in a Hispanic immigrant and refugee community.
This article introduces a framework for the study of access to medical care that has been used extensively in national and local surveys, and demonstrates its application to an assessment of health and health care needs in a Hispanic immigrant and refugee community. The presentation of the framework, study design, findings, and implications for research and planning points out the utility of this framework for organizing systematic community assessment data-gathering activities; demonstrates how such an assessment could be incorporated into a public health nursing curriculum or readily adopted by public health nurse professionals in their communities; illustrates the potential for effective partnerships between public health practitioners and academics in conducting and disseminating the findings; and provides a broader conceptual, empirical, and policy-oriented context in which to view local community-assessment activities and their relevance for health policy and program development.
Adolescent↗
Identifying families at high risk of cardiovascular disease: alternative work site approaches.
By examining coverage, concordance, and costs, this project evaluated four methods of cardiovascular disease (CVD) risk screening at a work site with 1821 central office employees of an energy company in Houston, Tex. Screening methods included a health risk appraisal mail questionnaire (HRA), an HRA plus brief physical assessment, an analysis of medical claims data, and an analysis of absenteeism data. Coverage ranged from 99% of employees for the absenteeism method to about 30% for the HRA method. Combining the first three screening methods, 18% of families had at least one member with a CVD or related diagnosis or one of four major CVD risk factors. The absenteeism method yielded 12.1% of the central office employees with 9 or more days absent. Although the absenteeism method identified high-cost families, only 9% had a heart disease or related diagnosis. This lack of concordance also occurs with other methods. For example, only 9.4% of families identified with the claims data were also identified by the HRA. Therefore, the methods identify different groups of high-risk families. Findings are discussed in relation to costs and other factors important to firms' selection of screening methods.
Absenteeism↗
Evaluation of a primary health care program for the poor.
This paper examines the success in implementing a major program involving a partnership between public and private providers to deliver primary health care services to the poor. In 1985, the 69th Texas Legislature passed the Primary Health Care Services Act, authorizing the Texas Department of Health to contract for or directly provide primary health care services in those parts of the state that are medically underserved and have large numbers of people in poverty. This paper evaluates the potential impact of the projects with respect to access and cost. The study revealed that the basic concept of allowing local public and private providers to develop projects reflecting their community's unique needs and resources was successful. The approach lead to a wide variety of different types of projects, but the basic goals and activities of the projects are consistent with the legislation. The evaluation identified three major program areas that could be improved: (1) patient monitoring and follow-up to ensure the accessibility of the priority primary care services, (2) the need for the development of projects in other high need areas of the state, and (3) greater efficiency in service delivery.
Health Resources↗
Home care for ventilator-assisted children.
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Child↗
National Study of Internal Medicine Manpower: XIII. The financing of internal medicine residency and fellowship training, 1985 to 1986.
Hospital revenue is the most important source for residency and fellowship stipends in internal medicine. Medicare is especially important for residency programs in voluntary hospitals and hospitals not closely affiliated with a medical school. In the last decade state and local government support and federal training grant support for residency stipends declined, whereas Veterans Administration support increased. Fellowship stipend sources are much more diverse; federal training grants, professional fees, foundations, medical school funds, and research grants contribute significantly. Medicare support appears to be focused on subspecialties particularly important to the elderly, including critical care, rheumatology, cardiology, hematology, gastroenterology, and nephrology. Geriatric medicine, however, receives substantial Veterans Administration support. With growing revenue constraints and increasing concerns about excess physicians we need to monitor the impact of government regulations and other factors on funds available for training internal medicine specialists.
Economics, Hospital↗
National Study of Internal Medicine Manpower. XII. The future of graduate medical education in internal medicine: what do program directors predict?
The 1985-1986 National Study of Internal Medicine Manpower asked directors of residency and fellowship programs about their plans to change the size of their programs in the near future. The vast majority (71% to 76%) of the directors expected their programs to remain about the same size for the next couple of years. For fellowship directors, this reflects a decline in the number planning to increase their program size since 1976-1977 from 32% to 18%. Directors of programs that are principal affiliates of medical schools are more likely to plan a decrease, while Veterans Administration directors are more likely to plan an increase in program size. The reason residency directors cited most frequently as important to their plans to increase program size was a perceived shortage of internists. Fellowship directors most frequently cited the need for fellows in clinical research. Stipend availability was the most important factor that influenced plans to decrease program size. Overall, residency and fellowship directors planned to increase the size of their programs around 1%. Program directors and others in the internal medicine community should consider how they can change the stipend availability, admissions criteria, and other incentives to channel trainees into the areas of greatest potential need and demand for the profession.
Education, Medical, Graduate↗